Special considerations for a unique vaccine
2016 update
for a unique vaccine
2016 update
© World Health Organization, 2017
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization..
Suggested citation. HPV vaccine communication. Special considerations for a unique vaccine: 2016 update. Geneva: World Health Organization; 2017 (WHO/IVB/17.02). Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
Printed in Switzerland
Who should use this guide? ...3
the structure ...3
PART I – The basics: good communication practices for immunization ...5
changing human behaviour: a process ...6
communication principles...7
the theory, reality and need to advocate for communication ...8
a note on country context ...9
the essential elements for communication planning ...10
Sample HPV monitoring plan ...18
Sample HPV communication plan ...20
PART II – HPV vaccine: considerations for communication ...23
Why HPV vaccine is unique ...23
Getting started: what to consider and what to do ...28
HPV vaccine in communication planning ...32
effective messages ...40
materials and channels ...45
crises ...47
Conclusion and summary ...48
conclusion ...49
Summary: planning and considerations for HPV vaccine ...50
Annex – Crisis communication for HPV vaccine ...57
Be prepared ...58
implement: when crisis occurs...60
cautions and lessons from global experience with HPV vaccine ...64
FAQ, materials and resources ...66
Frequently asked questions ...67
materials ...72
examples of HPV vaccine websites with sample materials ...73
Resources ...74
published by the London School of Hygiene and Tropical Medicine and PATH inform this work.* Immunization programme managers and their teams in Latvia, Malaysia and Rwanda helped the author learn about and understand the issues through field visits. WHO also thanks the health workers, headmasters, teachers, community leaders, mothers, fathers and girls who took the time to share their thoughts, and through this, help us do a better job.
The original 2013 version of this guide and this 2016 update were written by Christine McNab. Paul Bloem, Tracey Goodman and Susan Wang of WHO’s Immunization, Vaccines and Biologicals Department provided technical oversight. Scott LaMontagne of PATH and Abdelkader Bacha and Jonathan Shadid of UNICEF provided comments on the 2016 update.
A short note on terminology
In this guide, “communication” encompasses the areas of advocacy, social mobilization, behaviour and social change and crisis communication.
What is new in this guide
This updated version of the guide reflects:
1. WHO’s October 2014 changes to the recommended HPV vaccine schedule.
2. Updated facts, evidence and experience from low, middle and high-income countries that have introduced HPV vaccine.
3. An enhanced section on crisis communication.
4. Additional information about the opportunities for integration with comprehensive cervical cancer programs and adolescent health interventions and on the consent process.
HPV vaccine presents some challenging issues for communities. Concerns about the HPV vaccine are a common feature of its introduction. HPV vaccine is targeting girls before they become sexually active in order to prevent acquisition of a sexually transmitted infection (STI). WHO recommends that two doses of the currently licensed HPV vaccines be administered to 9–13-year-old girls to prevent infection with two types of human papillomavirus that account for about 70% of cervical cancer cases. The full benefits of HPV vaccine in reducing infection and the subsequent risk of cervical cancer will only be appreciated years and even decades after girls have been vaccinated.
Countries introducing HPV vaccine should invest in a communication plan for the introduction and sustained delivery of HPV vaccine so that it becomes positively associated with adolescent girls and a socially-acceptable demanded service.
This guide offers guidance in three main areas: the first is advice on basic communication planning and implementation for immunization; the second discusses specific considerations for HPV vaccine; and the third on crisis communication. The basic elements of an immunization communication plan include:
• building a cross-sectoral team;
• clear programme and communication objectives;
• understanding community knowledge, attitudes and practices;
• SMART objectives and sensible strategies;
• defined target audiences with activities and messages for each that use appropriate channels and materials;
• a crisis communication plan to manage problems including adverse events following immunization; and a monitoring and evaluation plan.
The specific considerations of HPV vaccine draw on the experience of countries which have either introduced the vaccine nationally or conducted demonstration projects, from partner experience, as well as from several reviews and evaluations in low, middle and high-income countries and the published literature. This part includes advice about cross-sectoral advocacy, team building and formative research; consent; a description of the recommended target groups; the importance of careful planning so that the messages reaches hard-to-reach girls; thoughts on integration with additional services, and advice about effective messaging, materials and communications channels.
Many countries introducing HPV vaccine have faced specific challenges or crises that required communication preparedness. The guide therefore includes a section on preparing for and implementing a crisis communication plan.
Finally, the guide includes summary tables, tips, frequently asked questions, sample materials and resources, all intended to provide immunization managers and communication specialists with the tools they need to ensure a high-quality strategic communication plan.
Special
conSiderationS
for a UniqUe
Vaccine
Human papillomavirus (HPV) vaccine has one of the highest per-person impacts on mortality of all vaccines.1 First licensed in several high-income countries in 2006, the vaccine is being steadily introduced into more countries. The World Health Organization (WHO) recommends vaccination for 9–13-year-old girls as the most cost-effective public health measure against cervical cancer, as part of a comprehensive cervical cancer control strategy. Given the vaccine’s unique characteristics and based on country experiences, WHO recommends investment in a communication strategy for the introduction of HPV vaccine.
Low- and middle-income countries, where more than 85% of cervical cancer deaths occur, can particularly benefit from HPV vaccine. By the end of 2015 more than 65 countries introduced national HPV vaccine programmes and a number of others had or planned to introduce pilot or demonstration programmes. The pace of introduction in low-income countries eligible for support from Gavi, the Vaccine Alliance, is increasing. More than 30 countries are approved presently for GAVI-supported demonstration programmes and national introductions.
Global and country experience in communication for immunization continues to grow as countries build on existing knowledge, add new vaccines and endeavour to increase equitable coverage of national immunization programmes. Despite this experience, challenges persist and new ones develop as the public health community struggles to engage some communities and families in immunization, leading to suboptimal coverage. The lower uptake of some vaccines can be caused by poor service delivery; a lack of knowledge about the threat of vaccine-preventable
1. Lee L et al. The estimated mortality impact of vaccinations forecast to be administered during 2011–2020 in 73 countries supported by the GAVI Alliance. Vaccine, 2013, Decade of Vaccines Supplement, 2:B61–B72. Specifically, the reviews finds that “First-dose measles, human papillomavirus, and hepatitis B vaccination are expected to have the highest per-person impact and avert 16.5, 15.1, and 8.3 deaths per 1000 persons vaccinated, respectively.”
Introduction
diseases, the risks and benefits of vaccines; complacency; mistrust of government, health workers and manufacturers; and alternative health or religious beliefs. These challenges underscore the importance of early integration and investment in a strategic communication plan including a crisis communication plan for immunization programmes.
There is a growing body of knowledge and information on HPV vaccine communication. In most low- and middle-income countries, demand and coverage with HPV vaccine is high. While HPV vaccine presents exciting opportunities for public health, experience reveals communication challenges in some countries and communities. People mistrust it because it is new and is mistaken for an experimental vaccine, targeted only at young adolescent girls, or they believe it will lead to increased sexual activity. In some countries, paediatricians, gynaecologists or religious leaders have misunderstood the purpose or value of HPV vaccine, leading to resistance and low coverage.
In a handful of countries, HPV vaccine has been rejected due to misinformation.
This guide summarizes good practices for HPV vaccine communication based on material from several sources, including country and partner experiences, the findings of country reviews;
recognized “best practices” for communication, advocacy and social mobilization for public health; and learning from other relevant programme and partner experiences.
Who should use this guide?
This guide should be read together with WHO’s Principals and considerations for adding a vaccine to a national immunization programme: From decision to implementing and monitoring and WHO’s HPV Vaccine Introduction Guide.2
National immunization managers, national and district social mobilization teams, partners and international agency staff involved in HPV vaccine introduction can use this guide to plan and implement a communication strategy for HPV vaccine introduction and its sustained delivery.
Additional partners involved in cervical cancer control, reproductive health, adolescent health, women’s health and other critical sectors such as education will also benefit from this guide.
Readers may also wish to consult resources on communication for immunization, health programming, cervical cancer, adolescent, sexual and reproductive health. Some key resources are listed at the end of this document.
The structure
n SPeCIAl ConSIdeRATIonS FoR A unIQue VACCIne
n PART I – THe BASICS
describes good public health communication practices and principles applicable to any country health communication programme.
n PART II – HPV VACCIne
HPV VACCIne: focuses on why HPV vaccine merits additional considerations, and describes key features countries should build into their HPV vaccine communication plans.
Considerations for communications – Crisis communication for HPV vaccine
n ConCluSIon And SummARy
Summary tables: a sample communication plan, diagrams and tips boxes throughout the document help guide the reader to the most important content.
n Annex: CRISIS CommunICATIon
n FAQ, mATeRIAlS And ReSouRCeS
– Frequently asked questions: offers basic guidance to answer common questions about HPV vaccine.
– materials and resources: included at the end of the report for reference and further study.
2. See http://www.who.int/immunization/programmes_systems/policies_strategies/vaccine_intro_resources/nvi_guidelines and http://
www.who.int/immunization/hpv/plan.
the BaSicS
Immunization should be a social norm, wherein the demand for and access to immunization for all members of every community is normal, socially acceptable health behaviour. The introduction of HPV vaccine should be approached as a long-term ongoing strategy to help prevent cervical cancer, and communities should demand it as a social norm for their adolescent girls. Strategic communication will help to create that norm.
Communication theories posit that people undergo a process to reach a decision to take a new action or to change a behaviour.3 This process usually begins with a person who is unaware of an intervention – such as vaccination. Through communication activities, they become aware, consider the intervention, adopt the intervention, repeat and demand it, and promote the intervention to their community. Strategic communication and engagement are a key parts of this process, along with the provision of high quality, accessible and reliable health services. This is an iterative process that can take time.
3. The different communication theories and approaches are documented and explained in other literature and will not be repeated here. For more on communication theories such as COMBI and C-Change, see the articles and resources listed on the Communication Initiative’s website: http://www.comminit.com. For information and resources on Communication for Development (C4D) see UNICEF’s website: http://www.unicef.org/cbsc.
Good communication practices for immunization
the introduction of HPV vaccine should be approached as a long-term ongoing strategy to help prevent cervical cancer, and communities should demand it as a social norm for their adolescent girls.
Changing human behaviour: a process
People generally undergo an iterative process towards taking a new action or changing a behaviour.
For example, over time a parent or caregiver may:
1. Be completely unaware of HPV vaccine.
2. Gain awareness through communication activities.
3. Consider accepting HPV vaccine based on knowledge gained from several sources.
4. Take action to have their daughter vaccinated.
5. Proactively take their second daughter for vaccination.
6. Promote HPV vaccine in their community.
Many factors play a role in the caregiver’s decisions, including understanding cervical cancer, the perception of risk of HPV infection, the degree of trust in the vaccine, the sources of information and the messages, the actions of friends and family and the daughter’s access to the HPV vaccine.
People generally go through an iterative process towards taking a new action or changing a behaviour.
CHAnGInG HumAn BeHAVIouR: A PRoCeSS
many factors play a role in the success, including the perception of threat of HPV and cervical cancer, the degree to which she trusts the vaccine, the message and its source, what action friends and family are taking and access to the HPV vaccine.
Be completely unaware
of HPV vaccine
2
3 4
Gain awareness through communication
Consider HPV vaccine based on
knowledge gained from several sources
Take action to have her daughter vaccinated
Proactively have her second daughter vaccinated
1
5
Communication principles
Health communication should adhere to key principles and be grounded in a human rights approach.
1. Promote community engagement
One goal of primary health care is for communities to own and demand the health programme or intervention. This can take time. Within communities, there will be many voices – some actively supportive, others passively accepting and some actively opposed. Communication should identify and engage all groups, their leaders and other influencers. It is human nature to want to learn, challenge assumptions and ask questions. Interpersonal communication and community participation will be key to successful communication. Over time this will produce improved, more sustainable health behaviours and outcomes.
2. Promote equity
Good public health practice is to ensure all people who need an intervention are reached. Yet, one in five children are not receiving the vaccines they need.
Many of these are marginalized and hard-to-reach populations. Sometimes these populations do not know a service is available, language barriers create misunderstandings, or a supportive environment is absent. Communication strategies should aim to
“reach the unreached” – families who may be day labourers, migrants, nomads and minority groups.
Reaching unvaccinated children including adolescent girls protects these communities, and is essential to achieve immunization and cervical-cancer control goals.
C4d promotes the following principles:
• Create spaces for a plurality of voices, promote narratives of communities, encourage listening, dialogue and debate and the meaningful participation of children and women.
• Inclusion, self-determination, participation and respect by ensuring that marginalized and vulnerable groups are prioritized and given visibility and voice.
• Link community perspectives and voices with sub-national and national policy dialogue.
• Address the whole person – including the cognitive, emotional, social and spiritual aspects in addition to survival and physical development.
• Build the self-esteem and confidence of parents, care providers, adolescents and children.
communication for Development Principles
United Nations agencies generally promote “Communication for Development” or “C4D”, a participatory process using advocacy, social mobilization, and social and behavioural change activities to empower individuals and communities to take actions and improve their lives.
The theory, reality and need to advocate for communication
Strategic communication requires investment.
Successful public health can be equated to a three- legged stool. One leg is availability of the intervention itself (e.g. the vaccine and logistics); the second is a trained, motivated cadre of health personnel; and the third is public acceptance and demand. Without the last element, the investment in the vaccines, logistics and health-worker training is wasted.
All of the elements described in the previous section represent the ideal for communication planning and implementation. However, experience shows that the ideal is sometimes far from possible.
In reality, health departments may have one or two communication/social mobilization officers working simultaneously on multiple projects. External partners might also be equally stretched. The time required to take all of these steps may not be available. Often, the situation analysis is done too rapidly with insufficient information. A national KAP survey may require several months to complete, while the programme may be scheduled to begin earlier. Funding may arrive late, seriously disrupting the plan. SMART objectives may have all been deemed
“priorities” but were in reality too numerous to achieve. Staff working on the project may have personal family matters that require their extended time away from work.
Communication activities are often under-resourced, but to achieve success in a public health programme, it is important to advocate for increased resources.
Planning is one way to make the investment case. A thoughtful communication plan which demonstrates, with evidence, how it will contribute to better public health outcomes is more likely to attract resources than a plan that proposes only IEC materials. Immunization programming can benefit from the number of partners involved in the communication working group. Get them involved early. Enlist their support to help with the situation analysis and the development of evidence-based plans. The preferred result is a persuasive communication plan with the resources required to achieve the desired public health outcomes.
HPV vaccine may be available, but if the population does not understand what it is for and why it benefits them, they will not automatically demand it. Worse, they may begin believing misinformation about it.
A note on country context
Some countries may not require as much investment in additional communication.
Countries where public confidence in government programming is high and where clear communication systems from national to community level may be able to use existing structures to communicate effectively about a new public health programme. People will accept and even demand the vaccination because they trust their leaders to offer health interventions that benefit communities and the country.
A note of caution: with increasing access to the Internet, much more information is available rapidly than previously.
This includes misinformation about HPV and other vaccines. The information may look official and cite researchers and other scientists. Anti-vaccination groups can make a compelling case to an untrained person who may already have questions about vaccines. Rumours can begin quickly in communities and be amplified nation-wide through mobile phones, inexpensive videos and social media tools.
Clear information can include:
• A cover letter to community leaders accompanied by a simple, concise question and answer document that helps community leaders explain HPV vaccine.
• Training and information, education and communication (IEC) materials for health workers so they understand the intervention and can communicate clearly and confidently with the community.
• Using the Internet to disseminate information. Some countries have established specific HPV vaccine websites in local languages that offer facts, answer common questions, address rumours and provide copies of IEC and media materials for easy download.
As a reference, the World Health Organization’s http://www.who.int/immunization/
diseases provides updated information about HPV, cervical cancer and all other vaccine preventable diseases.
therefore, it is important to ensure that, even in countries with high public trust and established communication systems, clear information in lay language is available to all target audiences including community leaders.
The essential elements for communication planning
An HPV vaccine communication plan includes the following basic elements.
1. A communication team
Countries generally assemble a team to work on communication for a health programme or intervention. This team, whether a sub-committee or working group, will be a key part of the larger planning team that may include operations, procurement, logistics and overall management. The team should include communication experts from government and relevant partner organizations and representation from the different sectors involved in the programme, such as youth and educators.
2. Technical programme objectives
The communication strategy must support achievement of the technical programme objectives.
In the case of HPV vaccine, this may be “to achieve > 70% coverage of the target population in year 1, > 80% in year 2, while reaching > 75% of hard-to-reach girls and increasing awareness of cervical cancer screening” to contribute to the achievement of cervical cancer control goals.
3. Situation analysis
A situation analysis forms the foundation for all communication planning and makes it possible to plan and budget for high-impact activities.
It also provides the baseline against which to measure progress. A situation analysis takes time and human and financial resources to do well – but without investment in this step, communication efforts and funds may be wasted on the wrong audiences with the incorrect messages and activities. The situation analysis should examine:
• Existing data sources including surveys (e.g. multiple-indicator cluster surveys (MICS) and demographic health surveys (DHS), immunization coverage surveys, school enrolment).
• Immunization programme information including reviews, administrative data, monitoring data.
• Knowledge, attitudes, practices (KAP) surveys and behavioural analyses of the main audiences.
• Reports from media, donors and other partners.
• Maps including social and satellite maps.
If there is insufficient existing information, formative research may be necessary. This can range from large KAP surveys to smaller samples including key informant interviews and focus group discussions in the target population.
4. SmART communication objectives
Based on the situation analysis, set “SMART” communication objectives that will express the specific ways in which communication activities can help to deliver the technical programme objectives. “SMART” is an acronym that means “specific, measurable, attain- able, results-oriented, and time-bound”.
Example: “Partner with the education sector so that teachers can provide three key messages about HPV vaccine to target age girls 10 days before the vaccine’s introduction.”
• TIPS
» objectives should be realistic. ensure they are not too ambitious and can be achieved in the time allotted.
» Prioritize the number of SmaRt objectives – do not set so many that they become overwhelming and unattainable.
5. Target audiences
Knowing the target population will help to ensure the right messages, materials, activities and languages.
• TIPS
» For some interventions the target audience may be quite broad – for example health workers or target-age girls.
» For others, it may be very specific: perhaps the director of health in one state or province or the president of an association.
6. define messages for each audience
Different audiences will respond to different messages. While there may be some common messages (e.g. x disease is dangerous and can be prevented), a health minister will be convinced by different information than a finance minister, and a mother may need different information than a health worker. Messages should:
• target the audience,
• be simple and easy to understand; no jargon, and
• include a call to action.
Ideally, messages should be based on a “message map” for each audience. The example below provides key messages and the supporting facts. These messages and facts form the basis for all communication materials, including brochures, media campaigns and training materials.
Stakeholder/Audience: rural female caregivers
Situation analysis: 90% of rural female caretakers surveyed know nothing about cervical cancer or HPV vaccine
SMART Objective: more than 65% of rural female caretakers know three messages about HPV vaccine before the 2nd dose is administered
Key MeSSAGe 1:
HPV vaccine protects girls from most cervical cancer.
Key MeSSAGe 2:
HPV vaccine is safe and effective.
Key MeSSAGe 3:
Protect your girls!
make sure all grade 6 girls receive two doses of HPV vaccine.
Supporting Fact 1.1 Cervical cancer is a leading cause of cancer in women in this country.
Supporting Fact 2.1 Health workers are trained to provide HPV vaccine safely.
Supporting Fact 3.1
The government immunization schedule recommends two doses of HPV vaccine for target age girls spaced six months apart (or not more than 12–15 months apart).
Supporting Fact 1.2 HPV vaccine protects against infection with HPV types that cause 70% of cervical cancer.
Supporting Fact 2.2
HPV vaccine is delivered with an auto-disable (AD) syringe that is used only once and then safely disposed.
Supporting Fact 3.2
Two doses are recommended by WHO to give optimum protection.
Supporting Fact 1.3 Research shows a decline in HPV infections in populations where HPV vaccine has been introduced.
Supporting Fact 2.3 Many studies conducted in developing and developed countries have found HPV vaccine to be safe and effective.
Supporting Fact 3.3
The exception are girls who are receiving HPV vaccine for the first time at age 15 or older, or girls who are immuno-compromised (e.g. HIV+).
These girls require three doses.
• TIP
» test the messages with the audiences. Rapid focus groups can help to ensure that people understand the messages and know what action to take.
7. A mix of strategies, activities and channels to reach the audiences
These should directly support achievement of the communication objectives. Audiences will be reached and engaged through a mix of strategies, activities and channels.
• Strategies are the approaches taken to achieve objectives and include advocacy, social mobilization, social and behaviour change, and crisis communication.
• Activities are the actions taken to support a strategy and can include, for example, advocacy meetings, creating strategic partnerships, discussions between the health worker and caretaker, publishing information materials and hosting media events.
• Channels are the ways in which a message reaches the audience, and can include influencers such as a health worker, family member, religious or political leader, the mass media or social media.
different audiences respond to different strategies, activities, and channels.
For example:
• A high-level advocacy meeting between the health team and finance minister may be the key activity required to remove a funding bottleneck.
• A mother may need to be reached through several channels including a
popular health radio programme, interpersonal communication with her trusted health worker, through a sermon at the church or a mosque announcement, and through the educational system, such as a letter to parents from the school headmaster.
different strategies and activities have very different cost implications For example:
• Television typically costs the most and may only reach those wealthy enough to own televisions.
• Mobilizing a trusted community-based organization to communicate about the programme in every village is also costly but may have more impact on parental demand and acceptance.
once audiences are identified, conduct a channel analysis to determine what information channels will be most influential with the specific audience. People are more likely to believe information from sources they trust. the communication plan should consider each channel of information and prioritise those that are the most trusted and have the widest reach within that audience. For many people, government endorsement is important. consider which radio programmes and newspapers people trust the most. trusted senior health practitioners can be good spokespeople. consider engaging a beloved actress who has daughters she will have vaccinated. in addition, consider minority groups who may trust different sources.
TRuST, InFluenCe And CHAnnelS
8. Create branded materials
The strategies and activities will have a bearing on the package of materials required. Materials should be tailored to the audience, and should be branded in a uniform way. They should include government and partner logos.
examples of materials include:
• Advocacy presentations.
• A list of key messages.
• Frequently asked questions (FAQs).
• “Issues management” advice.
• Information, education and communication materials (leaflet, posters, flipcharts).
• Training materials for health workers and teachers.
• A media kit for journalists.
Factors to consider:
• Materials should be clean, simple and legible.
• For non-specialists, materials should use images, simple graphics and fewer words.
• Materials should have a common look and “brand”, use a unifying logo, colour, type font and design scheme, together with government and partner logos.
• Pre-test the materials with the target audiences for appeal, relevance, comprehension, acceptability, persuasion and recall. In practical terms, a country team might test messages and materials at the same time.
• Use HPV vaccine materials to include short complementary messages about cervical cancer screening, adolescent health or routine immunization.
• Create a distribution plan so materials arrive in the right place on time.
• Include electronic distribution – by e-mail, through the Internet and through social media where available.
• TIPS
» is the language and artwork appropriate for illiterate populations or language minorities?
» are the physical depictions of people culturally appropriate, including for minorities?
» is there a clear call to action?
» How is the print quality? it can be tempting to save money by printing with low-quality ink and paper, but if the material fades or tears quickly, it may be money wasted.
» Will the material really be used? Posters, for example, can work well in a country where health clinics or schools routinely hang posters in a visible location, but not where distribution is poor or there is a lack of practical hanging tools such as sticky tape or thumb tacks.
9. A crisis communication plan
HPV vaccine has been subject to rumours and linked with adverse events following immunization (AEFI) in many countries.
Complacency, misinformation, adverse events and a lack of confidence in health systems can lead to a crisis in immunization programming, quickly eroding trust in EPI including HPV vaccine.4 Recovery from such a crisis can take years and can lead to extremely low immunization coverage rates over a prolonged period of time. Crisis preparation and management can avert costly problems.
The rise of Internet access and social media means that information – facts and rumours, celebration and scares - can spread more quickly than before. Events or public perceptions in other countries – even other continents – can have an impact on people’s understanding of and trust in vaccines. People who have questions, mistrust the health establishment and/or favour homeopathic medicine will find lots of information on the Internet that supports their views, and can spread this information through their social networks. This misinformation can result in greater risk of a crisis if there is a serious AEFI, including those that turn out to be unrelated to vaccination.5
The Global Vaccines Safety Blueprint recommends that every country develop a vaccine safety communication plan as part of an integrated communication plan, aimed particularly at communities, health care workers and decision-makers. The Blueprint stresses that any vaccine safety concerns should be investigated and promptly communicated appropriately.6 Crisis communication for health has become more evidence-based over time – with experience drawn from misinformation related to HPV and measles-mumps-rubella, Severe Acute Respiratory Syndrome, H1N1, multiple crises in polio eradication, Ebola in west Africa, and other health emergencies.
For more on crisis communication, see page 57 of this guide.
4. There are several examples listed in Building Trust and Responding to Adverse Events Following Immunization in South Asia: Using Strategic Communication, UNICEF ROSA, 2005.
5. For more on AEFI surveillance, including investigation, analysis and communication, see theGlobal Manual on Surveillance of Adverse Events Following Immunization; WHO, 2014, http://www.who.int/vaccine_safety/publications/aefi_surveillance.
6. World Health Organization: Global Vaccine Safety Blueprint; 2012.
10. A monitoring and evaluation plan
Communication-specific outcomes can be difficult to measure as communication efforts tend to contribute to overall programme outcomes. Nonetheless, the communication plan should include monitoring and evaluation components.
Implementing a monitoring plan with clear indicators can determine whether the plan is on track and focus on where to make adjustments. It will form the basis of reports to programme managers, oversight bodies and donors.
A mid-term or end-of-project evaluation will highlight project challenges and outcomes and can make recommendations to guide future programmes in the country and globally.
A monitoring and evaluation plan requires contemplation about objectives, targets and milestones, together with indicators and methods to assess the plan’s outcomes.
Set overall targets based on the SmART objectives to track progress and achievements.
Example – By Year 3:
• > 90% of teachers of target age girls know why girls should be vaccinated.
• > 75% of caregivers can describe how to prevent cervical cancer.
• > 80% of hard-to-reach girls know where to access HPV vaccine.
Set milestones as interim goals towards achievement of the plan.
Example – By year 1:
• 100% of health workers in 6 districts are trained in interpersonal communication.
• 75% of caregivers report they have attended a community meeting about HPV vaccine.
Set indicators – including input, output/process and outcome - against which to measure progress.
Input indicators: track the resources or “inputs” invested into the programme (e.g. staff, volunteers, funds, equipment)
Examples:
• Number of staff hired on time.
• Percentage of funds released by a certain date.
• Number of documents produced on time.
Output/process indicators: track the activities and products completed (e.g. training workshops, community meetings held, radio announcements aired).
Examples:
• Number of interpersonal communication training workshops held at district level on time.
• Number of radio announcements aired on radio prior to introduction.
• Number of IEC packages delivered to health centres on time.
Outcome indicators: track the results or changes in the target population as a result of the activity.
Examples:
• % of teachers who know three key messages about HPV vaccine.
• % of caregivers who cite health workers as the source of information about HPV vaccine.
• % change in vaccine uptake in a formerly vaccine hesitant area.
For example, coverage surveys should include questions about “source of information”
that can reveal whether communities are learning about HPV vaccine through the channels prioritized in the communication plan, “reasons for accepting vaccination” that can show whether communication played a role and “reasons for non-vaccination” that may uncover the circulation of rumours or other problems.7
Ideally, an independent external evaluation should be part of the plan and budget. If this is not possible, an honest internal evaluation with partners could also be scheduled. In order to assess outcomes, a programme may require a larger survey (such as a KAP survey) or use different sources of information including key informant interviews, coverage surveys, post-introduction evaluations, rapid exit surveys, programme monitoring, reports and information published in the media.
• TIPS
monitoring indicators require:
» a baseline to know the starting point against which to measure progress.
» Setting priorities: do not monitor everything. Pick things that are realistic to monitor and will demonstrate progress and challenges.
» a validation source: e.g. from supervisory reports, rapid surveys, monthly reporting.
» a frequency for validation: e.g. quarterly.
» incorporation into existing ePi reporting tools as much as possible – such as administrative reporting tools, coverage surveys, or post-introduction evaluations.
7. Waisbord et al. examine real-time communication monitoring in Communication for polio eradication: improving the quality of communication programming through real-time monitoring and evaluation. Journal of Health Communication. 2010, 15 Suppl 1:
9–24.
SMART objective / Target
Within three years, 90% of teachers of target age girls know three key messages about HPV vaccine Activity
annual teacher orientations Baseline
10% of teachers know why girls should be vaccinated Indicators
• Input indicator
number of information leaflets printed per teacher – Validation: communication team reports
– Frequency: one per year
• Output indicator
Percentage of teachers attending orientation meetings – Validation: orientation sign-in sheets and teacher registries – Frequency: one per district per year
• Outcome indicator
Percentage of teachers who can provide three key messages about HPV vaccine – Validation: Survey
– Frequency: one per year with HPV vaccine monitoring
11. A work plan with a budget
Once the essential elements of the communication strategy are mapped, integrate them into a work plan. The work plan should include a list of activities, the responsible person, the funds required for each element, the deadline for each activity and space for status reports. The work plan and budget may need to be authorized by the national programme coordination group.
Sample HPV monitoring plan
12. Adjust the work plan as required
Communication is a continuous process, with the goal of ensuring HPV vaccination becomes a social norm. The plan will need refining as the programme continues. If monitoring and other reports indicate an activity is not working as anticipated, it should be stopped or adjusted. Investments in communication may change over time as a programme becomes more integrated into the community and accepted as a regular part of health programming.
Programme objective
Achieve more than 90% coverage of Grade 5 girls and 10-year-old out-of-school girls with two doses of HPV vaccine this calendar year.
Situation analysis
In the majority population
In most of the country, 10% of target-age girls are not in school, for a total of 50 000 girls.
Based on demographic surveys and knowledge of the culture, about 80% of out-of-school girls are helping in the home, and 20% are working in the family business (shops, street stalls, small restaurants). Community attitude towards immunization is positive (e.g. DTP3 = 87%). A new community survey shows that 60% of female caregivers know very little or nothing about cervical cancer and that 90% of female caregivers know very little or nothing about HPV and HPV vaccine.
Previous experience in the country shows that these caregivers trust the First Lady and primary health-care workers. Almost every community listens to the 18:00 national news on the radio.
In the minority population
In six districts of “x” Province, more than 80% of target-age girls are not in school, comprising 10 000 target-age girls. They mainly work on their family farms. Community attitudes about immunization are less positive (e.g. DTP3 = 70%). The community survey shows that 80% of female caregivers know very little or nothing about cervical cancer and that almost 100% of female caregivers know very little or nothing about HPV and HPV vaccine. Previous experience shows
Sample HPV vaccine
communication plan
Sample communication plan
SMART objective
80% of caregivers can answer three basic questions about cervical cancer and HPV vaccine by the end of the year.
Target audiences
1. Caregivers of Grade 5 girls, and 10-year-old out-of-school girls in the majority population messages – Cervical cancer is a leading cause of death for women in our country.
– A virus called human papillomavirus, which is transmitted through sexual activity, causes cervical cancer.
Most women will get this virus when they are younger. Some will develop cervical cancer.
– We are offering a safe, effective vaccine that will prevent most cervical cancer.
– All Grade 5 girls in school, and 10-year-old girls not attending school should be vaccinated.
– Protect your daughters. Be sure they receive 2 doses of the cervical cancer vaccine this year.
Strategies, activities,
& channels
– Advocacy: with First Lady and ask her to launch HPV vaccine one week before introduction.
– Social and behavioural change with community: HPV vaccine community information session in every catchment area.
– Social and behavioural change through radio media: public service announcement to run before the 18:00 national news every day for two weeks before and during the week of introduction.
2. Caregivers of 10-year-old girls in minority population in “x” Province.
messages Same as above with these additions:
– HPV vaccine is safe and is used in neighbouring countries,
– Bring your 10-year-old girls to discuss the HPV vaccine with your community midwife, and have her vaccinated.
Strategies, activities,
& channels
– Social and behavioural change: orientation meeting with with midwives and religious leaders.
– Midwives lead community information sessions with religious leaders present in all catchment areas.
Materials
1. Branded promotional materials for launch. Launch speech for First Lady.
2. training package including interpersonal communication (iPc) skills for all health workers and teachers responsible for immunization.
3. Package of iec materials (poster, leaflet) to be used at community information sessions.
4. three versions of the public service announcement.
5. Same as above in local language.
6. orientation package for midwives and religious leaders.
Targets
1. Launch covered on all major media.
2. 90% of community meetings held.
3. 60% of people surveyed cite PSa as a source of information.
Indicators
– Input: % of iec materials arrived in time for the health information session.
– Process: % of community information sessions held.
– Outcome: % of caregivers who can answer three basic questions about HPV vaccine and cervical cancer.
Note: this is not a comprehensive plan, and data and information have been created only for the purpose of this exercise.
hpV Vaccine
This section outlines the elements of the communication planning process discussed in the last section and identifies key considerations for the introduction of HPV vaccine. The section also looks at broader, common lessons that have emerged from low-, middle- and high-income countries.
Why HPV vaccine is unique
HPV vaccine is different in several ways from other new vaccines targeted at infants.
Characteristics
of HPV vaccine Potential communication issues Targeted at pre-adolescent and adolescent girls
– may be in or out of school; if out of school, harder to reach.
– concerns about girls’ fertility and sexual activity.
– concerns about why the vaccine is not available to all women or to boys and men.
An injected vaccine
– Fear of injections amongst target-age groups.
– Higher risk of mild aeFis including fainting.
Considerations
for communication
Characteristics
of HPV vaccine Potential communication issues A newer vaccine
– concerns about safety, side-effects and efficacy, or “experimentation”.
– concerns about manufacturing origin; whether it meets religious standards (e.g. halal).
A relatively expensive vaccine
– concerns from health professionals, including gynaecologists, about budget priorities.
Provided in a two-dose schedule in a six-month (or 12–18 month) timeframe – maintaining support of schools for multiple health worker visits.
– Reaching girls who drop out, change or are not in school with both doses.
Protects against HPV – a little-known sexually transmitted infection
– explaining HPV infection risks and prevalence in clear, non-judgmental and culturally appropriate terms.
– not confusing with HiV or other sexually-transmitted infections.
Protects against cervical cancer which manifests years after HPV infection – cervical cancer may not be well-known or easily discussed.
– Gaining and maintaining support when the benefits of HPV vaccine may not be seen for several years, unlike vaccines against outbreak-prone vaccine-preventable diseases like measles.
Protects against 70% of cervical cancersa
– explaining that it does not protect against all causes of cervical cancer.
– explaining that cervical cancer screening is still necessary.
– explaining that cervical cancer screening is necessary but may not be widely availablea.
of interest to several disciplines and sectors
– opportunity to involve immunization, child health, adolescent health, HiV/Stis, cancer, sexual and reproductive health and education partners.
– opportunity to integrate communication strategy and messaging with several areas including cervical cancer prevention, adolescent health, education and others.
a. By July 2016, WHO had prequalified bivalent- and quadrivalent-HPV vaccines, which protect against 70% of cervical cancers.
A 9-valent HPV vaccine, which protects against up to 90% of cervical cancers was under review for pre-qualification by WHO.
(continued)
Country
experience:
snapshots
Countries have learned several lessons about communication for HPV vaccine introduction.
Here are a few excerpts of reported experiences, both positive and challenging. most of these experiences were reported at the november 2015 WHo Global learning meeting on HPV Vaccine Introduction.
Importance of mappIng stakeholders and buy-In
one european country experienced high resistance from several health associations, which publicly branded introduction of HpV vaccine as too expensive. their resistance sparked additional questions and concerns from health workers and parents, and contributed to low coverage.
one african country was surprised when the human rights commission – which was not invited to the initial stakeholder meetings – threatened to sue the government as it had misunderstood HpV vaccine to be an experimental new intervention that might damage girls’ fertility. days before implementation the country immunization manager had to act quickly and meet with the commission to explain the purpose and safety of HpV vaccine.
a southern african country says one of the biggest success factors for introducing HpV vaccine was involving parent–teacher associations and teachers’ unions. they could mobilize girls for immunization and help solve problems reaching school girls.
consIderIng consent
countries use different approaches to consent, ranging from more formal, written or verbal consent to more informal, implied consent procedures between health workers and caregivers. these provide both opportunities and challenges.
one south-east asian country successfully uses a written consent form that is sent home to parents for signature. Without written consent, girls are not vaccinated. the form also includes an aeFi checklist for parents to report even mild adverse effects to the health system.
other countries use “implied consent” where all caregivers are invited to a community information or parent teacher association meeting and informed about HpV vaccination.
the health workers then consider that consent has been given for all girls that come for vaccination in the community or school.
several countries report that by not seeking formal consent for routine immunization, some communities became suspicious when this was introduced for the HpV vaccine, and wondered whether the vaccine was experimental.
Many countries note that regardless of the consent process used in public schools, private schools tend to insist on “opt-in” consent forms distributed to every girl and signed by caregivers.
WorkIng WIth tradItIonal and relIgIous leaders
countries report there are several examples of how working, or not working with religious leaders affected the acceptance of the HpV vaccine.
one african country reports that it made a special effort to engage the chief of a district, who was also the head religious leader. the good news was that all of his followers brought their girls for HpV vaccine immunization.
the challenge was they had not engaged the minority religious leader in the area. the result? His followers did not bring their girls for vaccination. the lesson: engage religious and traditional leaders who will appeal to different populations in the community.
one south-east asian country’s religious leaders issued an islamic fatwa nationally, declaring the HpV vaccine to be safe and important for girls’ health.
messages and materIals
countries report it is important to keep messages simple and jargon-free. However, many stress the importance of creating different types of information packages for different audiences. this includes more sophisticated messaging for media that, for example, will address concerns people may have read on the internet.
consIderIng translatIon and consIstency
One language – one pacific country reports that though populations speak multiple languages, it elected to maintain all HpV vaccine materials in english – which is nationally understood – so
Multiple languages – other countries report that translation is essential for each language group.
Consistency across materials – Mistakes observed include the county that printed slightly different information about the target age group on different materials as there had been no final proof-reader.
comprehensIve cervIcal cancer preventIon and control
some countries promote a dual message for their populations: “Girls, get vaccinated now to protect your future! Mothers, get screened to protect your health today!” When promoting screening, it is important that screening services are available.
adolescent health IntegratIon in one southern african country, health workers distribute a “Me, My Body, My life” magazine to all grade-4 students while HpV vaccine is being administered as part of the school health programme. Boys and girls receive the magazine so that boys also benefit from the HpV vaccination session. students can read a range of topics including puberty, immunization, bullying, exercise, resisting alcohol and drugs, and then answer questions, do activities, and write journal-style entries about the topics. there are references to help- lines and the importance of talking to trusted adults if they have concerns or questions.
fundIng and sustaInabIlIty
late release of funds: one country prepared and pre-tested high-quality materials in several languages. However, due to the late release of funds, the country had to print and distribute the materials many weeks after HpV vaccination began. “We had to convince people
them,” said one health leader. this caused undue concerns in the community and short- term problems for the programme.
sustaining funding – one high-income country reports parental difficulties to find the latest information, due to the reduction in the communication budget in the years following the HpV vaccine’s introduction. “there is a new cohort of parents and girls every year,” said
one cervical cancer expert from the country,
“and they need to have access to clear and updated information.” the lesson: ensure a sustained communication budget.
including communication in procurement:
some middle-income countries report the negotiations for vaccine procurement ensure the manufacturers include funding for the communication strategy.
1
Me
My life My body
A magazine for Grade 4 learners
WATER
Getting started: what to consider and what to do
experience from other countries suggests the several broader lessons for HPV vaccine communication.
Start early
While not unique to HPV vaccine, it is best to start communication planning early. Given the distinctive attributes of HPV vaccine and the potential for community concerns, planning several months in advance of introduction allows for the research, situation analysis and pre-testing needed to successfully introduce this new vaccine. Starting early also means having budgets approved early – which translates into materials that are ready on time.
Build a cross-sectoral team
HPV vaccine may be delivered through the existing immunization structures, but the health implications and benefits cut across many sectors and programmes.
The programme planning team and the communication team should integrate relevant sectors early. Each country should map all relevant sectors. These can include:
• the cervical cancer team,
• women’s health practitioners, including gynaecologists and obstetricians,
• adolescent health practitioners including paediatricians,
• the Ministry of Education,
• groups such as women’s, girls, youth and education associations,
• service clubs - such as Lions and Rotary – which are often involved in immunization,
• religious organizations and associations, or
• relevant counterparts in UN agencies such as WHO, UNICEF, and UNFPA, and international NGOs such a PATH and other local partners.
Working across sectors and programmes expands human and financial resources, taps existing knowledge, promotes new ideas and builds large networks that can reach people at all levels of society with consistent messaging. Building a strong multi-sectoral partnership is also an opportunity to ensure no group feels its “territory” is being threatened. At the same time, this approach requires more time to harmonize agendas and build consensus around messages and activities.
Planning early means budgets can be approved early – ensuring that implementation can take place on time. a review of country experiences showed that implementation ran more smoothly when social mobilization activities began at least a month before introduction.8
There will be concerns
Country experience shows that some communities and health workers will have concerns about HPV vaccine. Countries can anticipate concerns and rumours about:
• The source and relative newness of the HPV vaccine – The vaccine may be perceived to be a new experimental product from wealthy countries that is being tested in poorer countries.
• The words “demonstration project” can also trigger suspicion that this is an experimental vaccine. Some countries undertaking Gavi-supported “demos” have called it a “learning process” or found other ways to describe why just a few districts are being targeted.
• Communities and health workers may want more information about the safety, efficacy, side effects, long-term effects and experiences with HPV vaccine in other countries.
• The targeting of young girls – Some people may wonder if HPV vaccine will have an impact on girls’ fertility. They may take the idea further and suggest there is a plot to sterilize girls. Others may wonder if vaccination will encourage girls to become promiscuous, despite studies that demonstrate otherwise.9 Recognizing that HPV is an STI, some may misunderstand the need to vaccinate girls early, protest that their girls are not yet sexually active and believe that vaccination is not yet necessary. People may wonder why boys are not being vaccinated too as is happening in a few countries.
Women may wonder why older adolescents and adult women are not being vaccinated.
• The cost of the vaccine to the national health budget – In countries paying for the vaccine with national funds, professional health associations may wonder why HPV vaccine is being introduced given its expense and fear this may impact decisions to fund other vaccines or services such as cervical cancer screening and treatment.
Advocacy with groups that may have specific concerns
Some influential groups – such as health professional associations, private schools, parent- teacher associations, religious associations, other civil society actors - may have specific concerns about HPV vaccine which, if unaddressed, can lead to serious consequences. They can interrupt HPV vaccine delivery with one widely publicized news release. These groups may mistakenly focus on girls’ fertility or sexuality. They may question whether the vaccine meets standard religious criteria
9. Several studies show that HPV vaccine has no correlation with promiscuity or with neurological disease. For example, a study of more than 260,000 girls, published in 2014 found that concerns over increased promiscuity following HPV vaccination are unwarranted, with strong evidence that HPV vaccination has no significant effect on clinical indicators (STIs, pregnancy) of sexual behaviour. See:
Smith, L et al. Effect of human HPV vaccination on clinical indicators of sexual behaviour among adolescent girls: the Ontario Grade 8 HPV Vaccine Cohort Study. CMAJ, 8 December 2014. A 2014 Scandinavian study showed no correlation between HPV vaccination and multiple sclerosis. See: Nikolai Madrid Scheller et. al. Quadrivalent HPV Vaccination and Risk of Multiple Sclerosis and Other Demyelinating Diseases of the Central Nervous System. JAMA. 2015;313(1):54-61. doi:10.1001/jama.2014.16946. For more on HPV vaccine’s safety profile, see this report from the Global Advisory Committee on Vaccine Safety: http://www.who.int/vaccine_safety/
committee/topics/hpv/dec_2013 and this WHO 2014 position paper: http://www.who.int/wer/2014/wer8943.pdf?ua=1.
(e.g. halal). One country experienced high resistance from several health associations, which publicly criticized the introduction of HPV vaccine as being too expensive. Their resistance sparked more questions and concerns from health workers and parents, and contributed to low coverage which persisted for several years.
• TIP
» it is important to anticipate concerns, identify and engage with influential groups early. Discuss and address their concerns and bring them into a wider coalition – so that they not only tolerate HPV vaccine, but proactively support it.
understand and plan for the hard-to-reach girls
Hard-to-reach girls including those who are not in school may also be at higher risk of HPV infection and developing cervical cancer. These may include girls:
• who have low socioeconomic status,
• who remain home to help with child-rearing or the family business,
• living in remote regions,
• from minority cultures including nomadic groups,
• with disabilities,
• who move frequently with their families (e.g. migrant or seasonal workers),
• who attend school only part time,
• who have left home and live in dense, urban areas, or
• who are HIV-positive.
Some countries report it is very difficult to enumerate, locate, mobilize and immunize these girls.
One country reported very high coverage of girls in school (more than 95% administrative coverage) but much lower for girls out-of-school (less than 65%). While challenging, a communication plan should attempt to reach these girls through channels they trust – whether through household and community outreach, popular social media, messages through peer networks, adolescent friendly health services, housing, employment settings or popular youth venues. The messages should stress the risks of cervical cancer, benefits of the vaccine, the two-dose schedule and the fact the government is offering the vaccine free of charge.
The first year will have some challenges
Even with good preparation, challenges are likely to emerge during the first year of HPV vaccine introduction. These may relate to service delivery but can include rumours and misunderstanding about the vaccine. Good communication planning can anticipate this and provide audiences the information they need to understand and support the programme.
